Knowledge Translation/Quality Improvement

1. Knowledge Translation/Quality Improvement Marko Simunovic MPH, FRCS(C) Departments of Surgery, Oncology and Clinical Epidemiology and Biostatistics, McMaster University, Juravinski Cancer Centre, Hamilton Health Sciences April 29, 2009

2. Introduction • Define knowledge translation/quality improvement • Review QIRC trial • Paradox of quality improvement • ? New thoughts on KT/QI

3. Knowledge translation (KT) Effective, timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health system. Key is transfer/translation of knowledge Knowledge Translation Program, Faculty of Medicine, University of Toronto, Adapted from the Canadian Institutes for Health Research definition, 2001. Available at: www.ktp.utoronto.ca/whatisktp/definition.

4. KT Interventions Workshops Continuing education meetings Audit & feedback Local opinion leaders Educational outreach visits Tailored interventions

5. The QIRC Trial • Cluster randomized trial (hospital level) which began October 2001 • Optimize the use of TME rectal cancer surgery • 16 Ontario hospitals, 105 surgeons • Over 1015 patients accrued for primary outcomes • - rates of colostomy and local recurrence

7. Nagtegaal, JCO 2002

8. QIRC Trial 33 Ontario hospitals with an annual procedure volume for major rectal cancer resections of > 15 for the period April 1, 2000 to March 31, 2001 16 hospitals Ontario hospitals 105 surgeons 1015 patients Excluded: Participated in the QIRC pilot study (3 hospitals) Majority of rectal cancer surgery performed laparoscopically (2 hospitals) Surgeons at the hospital involved in the QIRC trial as rectal surgery experts (4 hospitals) 24 hospitals Approached 18 hospitals to participate Assessed for eligibility: 60% or more of surgeons at the respective site consented to participate Research Ethics Board approval Excluded: Research Ethics Board denied approval (2 hospitals) Randomized 16 hospitals Allocated to intervention (8 hospitals) Received QIRC strategy: Workshop Opinion leader Operative demonstration Post-operative questionnaire Audit & feedback Allocated to control (8 hospitals) Usual practice environment, i.e., onus is on the individual surgeon to obtain new knowledge or skills for any aspect of the care they provide

9. QIRC Strategy Workshops Selection of opinion leaders Operative demonstrations Use of opinion leaders Post-operative questionnaires Audit & feedback

10. RESULTS

11. Participation in operative demonstrations 20% 1Ryan B, Gross NC. (1943) “The diffusion of hybrid seed corn in two Iowa communities.” Diffusion of Innovations. Everett M. Rogers. New York: The Free Press. 4th ed, 1995. p 258.

12. Participation in operative demonstrations 1Ryan B, Gross NC. (1943) “The diffusion of hybrid seed corn in two Iowa communities.” Diffusion of Innovations. Everett M. Rogers. New York: The Free Press. 4th ed, 1995. p 258.

13. Participation in operative demonstrations 35% had a demonstration on their first case 76% by fourth case Participants treated 86% of patients 1Ryan B, Gross NC. (1943) “The diffusion of hybrid seed corn in two Iowa communities.” Diffusion of Innovations. Everett M. Rogers. New York: The Free Press. 4th ed, 1995. p 258.

14. Surgeons in experimental arm – all interviewed stated that involvement in QIRC strategy would change their provision of rectal cancer surgery. Wright FC et al; Quality initiative in rectal cancer strategy: A qualitative study of participating surgeons; J Am Coll Surg 2006; 203(6):795-802

15. QIRC trial – final patient outcomes

16. QIRC Strategy Workshops Selection of opinion leaders Operative demonstrations Use of opinion leaders Post-operative questionnaires Audit & feedback

17. Conclusions Negative trial Surgeons in Ontario are primed for change (i.e., high participation). There is a need for better tools to facilitate change – onus on researchers, policy makers and local champions.

18. Why did our trial fail? - implications • High participation, surgeon perceptions very positive • Not enough time to transfer TME expertise • APR vs LAR – attitude more than knowledge or skill • Did not influence pre-op processes of care • Resource intensity higher than most QI efforts – implications for policy makers and clinical leaders

19. KT interventions – Cochrane reviews 1) CME, meetings & workshops - minimal to no effects 2) Local opinion leaders – no effect 3) Audit & feedback – small to moderate effect Cochrane Collaboration. http://www.thecochranelibrary.com.

20. Three statements on quality that create a paradox: At any time point, one measures gaps in the Ql of care. Efforts to actively close such gaps usually fail. Over time the quality of care improves.

21. RCTs in Rectal Cancer *p<.05 Krook JE, et al. N Engl J Med 1991; 324:709-15. SRCT. N Engl J Med 1997; 336(14):980-7. Kapiteijn E, et al. N Engl J Med 2001; 345(9): 638-46.

22. New thoughts on KT/QI • Knowledge just one element – myriad others at personal, social, system level • LHIN4 quality improvement in cancer surgery • process of evaluation – shake confidence • process of support • ensuring stakeholders aware of need to constantly improve

23. A) Paradox of quality improvement – gaps present, difficult to actively close, care improves over time. B) KT/QI – need to test new approaches.

24. Overall age- and sex-adjusted carotid endarterectomy rates per 100,000 population 20 years and over in Ontario – 1981/82 – 1994/95 Data sources: CIHI, Ontario Ministry of Health

25. Concepts on new information & physician behaviour Concept 1: Awareness & response Physicians were aware and responded in a predictable manner.